ben grid
Benefits Grid1
This Clinical Services Benefits Grid includes the codes that are reimbursable for Family PACT (Planning, Access, Care and Treatment) Program procedures, medications and contraceptive supplies.
Family Planning Methods – Primary Benefits / Complications (5)Diag.
Code / Description / Procedures / Laboratory / Supplies / Medications / Diag. Code / Description
S101
S102 / Oral
contraception, patch, vaginal ring – Evaluation prior to method with or without initiation of method
Oral
contraception, patch, vaginal ring – Maintain adherence and surveillance / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
Screening Mammogram (6) / 80061: Lipid profile (1)(2)
80076: LFTs (2)
82465: Cholesterol
81025: Urine pregnancy test
82947: Glucose (3)
82951: 2hr GTT (3)(4) / None / X7706: OCs
X7728: Patch
X7730: Vaginal Ring
Z7610: Estradiol
X7722: Levonorgestrel
X1500:Spermicide, lubricant, M/F condom, sponge / S103
S1031 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Deep vein thrombosis
S201
S202 / Contraceptive injection –Evaluation prior to method with or without initiation of method
Contraceptive injection – Maintain adherence and surveillance / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
Screening Mammogram (6) / 80076: LFTs (2)
81025: Urine pregnancy test
82947: Glucose (3)
82951: 2hr GTT (3)(4) / None / X6051: DMPA
Z7610: Estradiol
X7722: Levonorgestrel
X1500: Spermicide, lubricant, M/F condom, sponge / S203
S2031 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Heavy vaginal bleeding
The following laboratory tests are for symptomatic or asymptomatic clients as clinically indicated based on individual client assessment. These tests are included under the primary diagnosis S-code and do not require a secondary ICD-9-CM code for reimbursement:
Screening tests / Reflex testing based on a positive screening test result / Pap smear codes
86592 / VDRL, RPR / 86781 / TP-confirmatory test; if positive, 86593 is required / 88141 / Physician Interpretation of Pap
86593 / Syphilis test, Quantitative / 88142 / LBC, manual screen
88143 / LBC, manual screen and re-screen
86701 / HIV-I / 86689 / HIV confirmation / 88147 / Smear, automated screen
86702 / HIV-II / 86689 / HIV confirmation / 88148 / Smear, automated screen, manual re-screen
86703 / HIV-I and HIV-II single
assay / 86689 / HIV confirmation / 88164 / Smear, Bethesda, manual screen
88165 / Smear, Bethesda, manual screen, re-screen
87081 / GC culture / ------/ None / 88167 / Smear, Bethesda, manual screen, computer re-screen
87491
87591 / NAAT - Chlamydia
NAAT - GC / ------
------/ None
None / 88174
88175 / LBC, automated screen
LBC, automated screen, manual re-screen
87800 / Direct Probe -
Chlamydia +GC only / 87490
87590 / Chlamydia direct probe
GC direct probe / For HPV tests, see Cervical Abnormalities
(1)Only if elevated screening cholesterol or significant risk factors for cardiovascular disease.
(2)Limited to one every six months per client.
(3)Limited to one per year per client.
(4)Only if history of abnormal fasting blood sugar screen.
(5)Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
(6)Refer to “Other Primary Services”section in this grid.
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Family Planning Methods – Primary Benefits / Complications (5)Diag.
Code / Description / Procedures / Laboratory / Supplies / Medications / Diag. Code / Description
S301
S302 / Contraceptive implant – Evaluation prior to method with or without initiation of method
Contraceptive implant – Maintain adherence and surveillance (including removal and reinsertion) / 11975: Insertion
11976: Removal
11977: Removal and insertion
Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
Screening Mammogram (6) / 80076: LFTs (2)
81025: Urine pregnancy test / 11976ZM: Removal / Z7610: Estradiol
X7722: Levonorgestrel
X1500:Spermicide, lubricant, M/F condom, sponge / S303
S3031
S3032
S3033
S3034
S3035 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Missing or deep capsule
Insertion/removal site infection
Insertion/removal site hematoma
Capsule expulsion
Heavy vaginal bleeding
S401
S402 / IUC – Evaluation prior to method with or without initiation of method
IUC – Maintain adherence and surveillance / 58300: Insertion
58301: Removal
Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
Screening Mammogram (6) / 81025: Urine pregnancy test
85013 – 85014: Hematocrit
85018: Hemoglobin / 58300ZM: Insertion
58301ZM: Removal / X1522: ParaGard
X1532: Mirena IUS
Z7610: Estradiol
X7722: Levonorgestrel
X1500: Spermicide, lubricant, M/F condom, sponge / S403
S4031
S4032
S4033 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Pelvic infection (secondary to IUC)
“Missing” IUC
Perforated or translocated IUC
The following laboratory tests are for symptomatic or asymptomatic clients as clinically indicated based on individual client assessment. These tests are included under the primary diagnosis S-code and do not require a secondary ICD-9-CM code for reimbursement:
Screening tests / Reflex testing based on a positive screening test result / Pap smear codes
88141 / Physician Interpretation of Pap
88142 / LBC., automated prep, manual screen
88143 / LBC., automated prep, manual screen and re-screen
88147 / Smear, automated screen
88148 / Smear, automated screen, manual re-screen
88164 / Smear, Bethesda, manual screen
88165 / Smear, Bethesda, Manual screen, re-screen
88167 / Smear, Bethesda, manual screen, computer re-screen
88174 / Preserv. fluid, thin prep., auto screen
88175 / Preserv. fluid, thin prep., auto screen, manual re-screen
)
86592 / VDRL, RPR / 86781 / TP confirmatory test; if positive, 86593 is required / 88141 / Physician Interpretation of Pap
86593 / Syphilis test, Quantitative / 88142 / LBC, manual screen
88143 / LBC, manual screen and re-screen
86701 / HIV-I / 86689 / HIV confirmation / 88147 / Smear, automated screen
86702 / HIV-II / 86689 / HIV confirmation / 88148 / Smear, automated screen, manual re-screen
86703 / HIV-I and HIV-II single assay / 86689 / HIV confirmation / 88164 / Smear, Bethesda, manual screen
88165 / Smear, Bethesda, Manual screen, re-screen
87081 / GC culture / ------/ None / 88167 / Smear, Bethesda, manual screen, computer re-screen
87491
87591 / NAAT - Chlamydia
NAAT – GC / ------
------/ None
None / 88174
88175 / LBC, automated screen
LBC, automated screen, manual re-screen
87800 / Direct Probe - Chlamydia +GC only / 87490
87590 / Chlamydia direct probe
GC direct probe / For HPV tests, see Cervical Abnormalities
(2) Limited to one every six months per client.
(5) Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
(6) Refer to “Other Primary Services” section in this grid.
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Family Planning Methods – Primary Benefits / Complications (5)Diag.
Code / Description / Procedures / Laboratory / Supplies / Medications / Diag. Code / Description
S501
S502 / Barriers and spermicide – Evaluation prior to method with or without initiation of method
Note: Includes fertility awareness methods and lactation amenorrhea method
Barriers and spermicide – Maintain adherence and surveillance / 57170: Diaphragm/ cervical cap fitting
Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
Screening Mammogram (6) / 81025: Urine pregnancy test / FAM / X7722: Levonorgestrel
X1500: Diaphragm, cervical cap, spermicide, lubricant, M/F condom, sponge BBT / S503
S5031 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Severe skin/tissue reaction
S601
S602 / Pregnancy testing
Note: Should be used only when the client is not seeking a contraceptive method
Confirmation of pregnancy test result / / 81025: Urine pregnancy test
Note: No additional laboratory tests are available with this S-code
The following laboratory tests are for symptomatic or asymptomatic clients as clinically indicated based on individual client assessment. These tests are included under the primary diagnosis S-code and do not require a secondary ICD-9-CM code for reimbursement:
Screening tests / Reflex testing based on a positive screening test result / Pap smear codes
86592 / VDRL, RPR / 86781 / TP confirmatory test; if positive, 86593 is required / 88141 / Physician Interpretation of Pap
86593 / Syphilis test, Quantitative / 88142 / LBC, manual screen
88143 / LBC, manual screen and re-screen
86701 / HIV-I / 86689 / HIV confirmation / 88147 / Smear, automated screen
86702 / HIV-II / 86689 / HIV confirmation / 88148 / Smear, automated screen, manual
re-screen
86703 / HIV-I and HIV-II single assay / 86689 / HIV confirmation / 88164 / Smear, Bethesda, manual screen
88165 / Smear, Bethesda, Manual screen,
re-screen
87081 / GC culture / ------/ None / 88167 / Smear, Bethesda, manual screen, computer re-screen
87491
87591 / NAAT - Chlamydia
NAAT – GC / ------
------/ None
None / 88174
88175 / LBC, automated screen
LBC, automated screen, manual
re-screen
87800 / Direct Probe -
Chlamydia +GC only / 87490
87590 / Chlamydia direct probe
GC direct probe / For HPV tests, see Cervical Abnormalities
(5) Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
(6) Refer to the Other Primary Services:Radiology section in this grid.
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Family Planning Methods – Primary Benefits / Complications (5)Diag. Code / Description / Procedures / Laboratory / Supplies / Medications / Diag. Code / Description
S701
S702 / Bilateral tubal ligation – Screening and evaluation
Surgical procedure / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
58600: Mini lap TL
58615: Mini lap TL with clip
58670: Lapscope fulguration
58671: Lapscope with ring or clip
Screening Mammogram (6) / 80076: LFTs (2)
81025: Urine pregnancy test
88302: Surgical path. (two specimens)
Preoperative tests
71020: Chest X-ray (7)
81000: UA dipstick w/microscopy
81001: UA automated w/microscopy
81002: UA dipstick w/out microscopy
81003: UA automated w/out microscopy
85013: spun Hct
85014: Hct
85018: Hemoglobin
85025: Auto CBC w/auto diff. WBC
85027: Auto CBC w/out differential
93000: ECG (7) / 58600ZM/ZN: Mini-Lap TL
58615ZM/ZN:Mini-Lap with clip
58670ZM/ZN: Lapscope fulguration
58671ZM/ZN: Lapscope ring or clip / X7722:
Levonorgestrel
X1500: Spermicide, lubricant,
M/F condom, sponge / S703
S7031
S7032
S7033
S7034 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Anesthesia complication: hospitalization
Abdominal injury; L/S or lap (within 30 days postop)
Operative site or pelvic infection (within 30 days postop)
Preop evaluation (TAR prospective)
The following laboratory tests are for symptomatic or asymptomatic clients as clinically indicated based on individual client assessment. These tests are included under the primary diagnosis S-code and do not require a secondary ICD-9-CM code for reimbursement:
Screening tests / Reflex testing based on a positive screening test result / Pap smear codes
86592 / VDRL, RPR / 86781 / TP confirmatory test; if positive, 86593 is required / 88141 / Physician Interpretation of Pap
86593 / Syphilis test, Quantitative / 88142 / LBC, manual screen
88143 / LBC, manual screen and re-screen
86701 / HIV-I / 86689 / HIV confirmation / 88147 / Smear, automated screen
86702 / HIV-II / 86689 / HIV confirmation / 88148 / Smear, automated screen, manual
re-screen
86703 / HIV-I and HIV-II single assay / 86689 / HIV confirmation / 88164 / Smear, Bethesda, manual screen
88165 / Smear, Bethesda, Manual screen,
re-screen
87081 / GC culture / ------/ None / 88167 / Smear, Bethesda, manual screen,
computer re-screen
87491
87591 / NAAT - Chlamydia
NAAT – GC / ------
------/ None
None / 88174
88175 / LBC, automated screen
LBC, automated screen, manual
re-screen
87800 / Direct Probe -
Chlamydia +GC only / 87490
87590 / Chlamydia direct probe
GC direct probe / For HPV tests, see Cervical Abnormalities
(2)Limited to one every six months per client.
(5)Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
(6)Refer to “Other Primary Services” section in this grid.
(7)As medically indicated for preoperative evaluation of a pre-existing medical condition, when medically indicated or required by outpatient facility.
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Family Planning Methods – Primary Benefits / Complications (5)Diag. Code. / Description / Procedures / Laboratory / Supplies / Medications / Diag. Code / Description
S801
S802 / Vasectomy –screening and evaluation
Surgical procedure / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered)
55250: Vasectomy / 88302: Surgical path (two specimens)
Preoperative tests
81000: UA dipstick w/microscopy
81001: UA automated w/microscopy
81002: UA dipstick w/out microscopy
81003: UA automated w/out microscopy
85013: spun Hct
85014: Hct
85018: Hemoglobin
85025: Auto CBC w/auto diff.WBC
85027: Auto CBC w/out differential / 55250ZM: Vasectomy / X1500: Spermicide, lubricant, M/F condom, sponge / S803
S8031
S8032
S8033 / Vaso-vagal episode
Allergic reaction to treatment for a secondary diagnosis
Testicular, spermatic cord hematoma, or hemorrhage (within 30 days post op)
Operative site acute infection (within 30 days post-op)
Post-op testicular pain (within 30 days post-op)
Post vasectomy semen analysis is included in the global fee for vasectomy.
The following laboratory tests are for symptomatic or asymptomatic clients as clinically indicated based on individual client assessment. These tests are included under the primary diagnosis S-codes for sterilizations and do not require a secondary ICD-9-CM code for reimbursement:Screening tests / Reflex testing based on a positive screening test result
86592 / VDRL, RPR / 86781 / TP confirmatory test; if positive, 86593 is required
86593 / Syphilis test, Quantitative
86701 / HIV-I / 86689 / HIV confirmation
86702 / HIV-II / 86689 / HIV confirmation
86703 / HIV-I and HIV-II single assay / 86689 / HIV confirmation
87081 / GC culture / ------/ None
87491
87591 / NAAT - Chlamydia
NAAT – GC / ------
------/ None
None
87800 / Direct Probe - Chlamydia +GC only / 87490
87590 / Chlamydia direct probe
GC direct probe
(5) Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
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Other Primary ServicesA primary diagnosis S-code is required for other primary services that may be subject to additional restrictions as noted.
Other Primary Services / Complications (5)Diag. Code / Description / Procedures / Laboratory / Supplies / Medications / Description
Use appropriate primary diagnosis
S-code / Hepatitis B immunization / None / None / 90743 – 90744, 90746: Hepatitis B vaccine
Modifiers required / Allergic reaction to Hepatitis B vaccine
Vaso-vagal episode
Use appropriate primary diagnosis S-code / Radiology / 76092: Screening film mammogram DOS thru 7/31/07 (21) (22)
77057: Screening film mammogram DOS on/after 08/01/07 (21) (22)
G0202 Screening digital mammogram
DOS on/after 12/01/06 (21) (22)
76083 CAD (computer aided detection) DOS on/after 12/01/06 thru 7/31/07 (23)
77052 CAD (computer aided detection) DOS on/after 08/01/07 (23) / None / None / None / Refer to the Benefits: Primary Contraceptive Services section for the reimbursable diagnostic radiology services for the client’s contraceptive method.
(5)Complication services require a TAR, unless stated otherwise. Refer to the Benefits: Primary Contraceptive Services section in this manual.
(21) Screening mammography, females 40-55 years of age, one per year, per client, any provider.
(22) One screening mammogram per year, per client, any provider either 76092, or 77057 or G0202.
(23) One CAD per year, per client, any provider. List separately in addition to code for primary mammography procedure.
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Secondary Benefits: For treatment or diagnostic testing of STIs, other than the previously
Management of Sexually listed primary screening tests, a secondary diagnosis ICD-9-CM code is
Transmitted Infections (STIs)required. HIV testing is a covered screening service, but treatment of HIV infection is not a reimbursable benefit of the program.
Secondary Benefits (9) / Complications (11)ICD-9-CM Diag. Code / Description / Procedures / Laboratory / Supplies / Medications (8) / Description
V01.6 / Use V01.6 for diagnosis and treatment of an asymptomatic partner exposed to active case of Chlamydia, Gonorrhea, Syphilis, or Trichomoniasis. / Primary benefit screening tests, wet mounts, and pH testing only / Treatment is based on the CDC STD treatment guidelines for the STI identified in the index case. / ---
099.41
099.52
099.53
099.40
604.90
616.0
V01.6 / Chlamydia
Urethritis
Anus/rectum
Cervicitis
Presumptive Dx
Male: NGU/NSU
Acute epididymitis/ orchitis
Female: cervicitis
Ct-exposed partner / None / 87205: Gram stain-symptomatic males only
Chlamydia screening tests included in primary benefit
(S-code) / None / Azithromycin
Doxycycline / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
098.0
098.12
098.15
098.6
098.7
099.40
616.0
V01.6 / Gonorrhea
Urethritis
Prostatitis
Cervicitis
Pharynx
Anus/rectum
Presumptive Dx
Male: NGU/NSU
Female: cervicitis
GC-exposed partner / None / 87205: Gram stain –symptomatic males only
GC screening tests included in primary benefit (S-code) / None / Azithromycin (10)
Cefpodoxime
Ceftriaxone / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
054.11
054.12
054.13
608.89
616.50 / Herpes (genital only)
HSV Vulvovaginitis
Herpes vulva
Herpes penis
Presumptive Dx
Male: penile ulcer
Female: vulvar ulcer / None / Additional Restrictions Apply (12)
87252: HSV culture
87255: HSV culture
87273: HSV DFA Type II / None / Acyclovir / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
614.0
614.2
615.0 / PID (uncomplicated outpatient only)
Acute PID
PID, NOS
Acute myometritis / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered) / 85025: CBC/diff
85651: ESR
85652: ESR
Chlamydia and GC screening tests are included in primary benefit (S-code) / None / Ceftriaxone injection
Cefoxitin injection
Doxycycline
Metronidazole
Ofloxacin
Probenecid / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
(8)Only dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See See the Pharmacy and Clinic Formulary section for additional information about regimen, formulation and coverage limits.
(9)Secondary diagnosis ICD-9-CM code required for any treatment or diagnostic testing beyond primary benefit screening tests.
(10)For patients with significant anaphylaxis-type allergies to penicillin or allergies to cephalosporins.
(11)Services to evaluate and manage a complication of treating a secondary condition require a primary diagnosis code (Sxx3). A TAR is required, unless stated otherwise. Refer to the Benefits: Secondary Related Reproductive Health Conditions section in this manual.
(12)Only as necessary to evaluate genital ulcers of unconfirmed etiology; payable for 616.50 (F) or 608.89 (M) only. Viral culture limited to Herpes simplex only. Reflex typing is not covered.
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Secondary Benefits (9) / Complications (11)ICD-9-CM
Diag. Code / Description / Procedures / Laboratory / Supplies / Medications (8) / Description
091.0
091.3
092.9
096
097.1
616.50
608.89
V01.6 / Syphilis
Primary
Secondary
Early latent
Late latent
Latent, unspecified
Presumptive Dx
Female: vulvar ulcer
Male: penile ulcer
Syphilis-exposed partner / Z5218: Collection and handling of blood specimen (when only service rendered)
Z5220: Collection and handling of blood specimen (when other services rendered) / 86593: Syphilis test quantitative (13)
Syphilis screening tests included in primary benefit (S-code) / None / Benzathine penicillin long acting - injection
Doxycycline / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
131.01
131.02
V01.6 / Trichomoniasis
Trichomonal vulvo-vaginitis
Trich. Urethritis
Trichomoniasis-exposed partner / None / 83986: pH (females only)
87210: Wet mount / None / Metronidazole
Tinidazole (16)
112.1
616.10 / Vulvovaginitis
Candidal
vulvo-vaginitis
------
Vaginitis/Vulvitis/BV / None / 83986: pH (females only)
87210: Wet mount / None / Butoconazole
Clotrimazole
Fluconazole
Miconazole
Terconazole
------
Clindamycin
Metronidazole / Allergic reaction to antibiotics used to treat STI
Vaso-vagal episode
078.0
078.10
078.11 / Warts (genital only)
Molluscum
Viral warts
Condylomata / 54050: Destruction of penile lesion; chemical (14)
54056: Destruction of penile lesion; cryo (14)
54100: Biopsy of penis (15)
56501: Destruction vulvar lesion (14)
57061: Destruction vaginal lesion (14)
56605: Biopsy, vulva (15) / 88304: Surgical path for males (15)
88304: Surgical path for females (15) / 54050ZM
54056ZM
54100ZM
56501ZM
57061ZM
56605ZM / Imiquimod
Podofilox / Allergic reaction to antibiotics used to treat STI
Severe genital skin ulcerations or infections
Vaso-vagal episode
(8)When applicable, only those dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See See the Pharmacy and Clinic Formulary section for additional information on regimen, formulation and coverage limits.